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Letter to the Editor

A successful collagenase and hyaluronic acid topical use

combined with antibiotic therapy in the treatment of

ulcerative lesions arising on tattoo

Paolo Fioramonti M.D.1, Maria Giuseppina Onesti M.D.1, Pasquale Fino M.D.1, Martina Ruggieri

M.D.1and Nicolò Scuderi M.D.1

1Department of Plastic, Reconstructive and Aesthetic Surgery

Sapienza University of Rome, Policlinico Umberto I,

Viale del Policlinico, 155, 00161, Rome – Italy

Correspondence to:

Pasquale Fino M.D.,

Department of Plastic, Reconstructive and Aesthetic Surgery,

University of Rome “ La Sapienza”, Policlinico Umberto I,

Viale Pantelleria, 35, Scala B, Interno 1/A, 00141, Rome, Italy.

Fax: +39 06 491525 - +39 06 64491523

e-mail: pasquale.fino@gmail.com, pasquale.fino@uniroma1.ii

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Letter to the Editor

A successful collagenase and hyaluronic acid topical use combined

with antibiotic therapy in the treatment of ulcerative lesions arising on tattoo

Dear Sir,

we present an unusual complication arose on a tattoo and the innovative use of collagenase to treat

it. Tattooing is an ancient art and is still widely practiced all over the world. After the procedure, a

wound healing process starts with an instantaneously acute inflammatory phase, followed by a

proliferative and maturation phase to restore tissue integrity 1. Skin complications include

infections, hypersensitivity reactions to pigments, chronic dermatoses and the development of

benign or malignant tumors on site of tattoo 2.

A 25-year-old man, two weeks after making a colorful tattoo on his right arm, showed the

development of four ulcerative lesions on it. They were about 0.5-1.0 cm in diameter, oval in shape,

with regular margins and net limits; there was an aura surrounding erythematosus; the bottom of the

lesion was covered by purulent discharge and abundant fibrin. (Fig.1) Furthermore, the patient

referred locoregional pain, itching and heat. A swab of wound secretions was performed and it

resulted positive for Staphylococcus aureus and Streptococcus pyogenes. So we have given the

patient oral antibiotic therapy based on clavulanic acid 875 mg and amoxicillin 125 mg (2 tablets /

day for 6 days). We also performed daily medication of ulcerative lesions disinfecting them with

Amuchina Med 0.05% and cutaneous solution based on 10% povidone- iodine and applying a film

of about 2 ml of Bionect Start® ointment on the lesions and zinc oxide paste onto the surrounding

skin. Bionect Start® is a topical cream containing hyaluronic acid, bacterial fermented sodium

hyalunorate (0.2 % w/w) salt and bacterial collagenase obtained from non-pathogenic Vibrio

alginolyticus (>2.0 nkat1/g) 3. The use of collagenase is based on performing lysis of fibrin and

necrotic tissue. The topical administration of collagenase increases the effect of macrophage

collagenase, which is responsible for wound debridement by splitting and breaking down proteins

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that hold the eschar (dead and devitalised material) over the wound 3. Bionect start® is shown to

provide an optimal moist environment and a wound preparation to facilitate the natural healing

process 4. This drug also contains hyaluronic acid (HA) which above all generates a

microenvironment stimulating the secretion of growth factors, proliferation and migration of

fibroblasts, endothelial cells, keratinocytes and angiogenesis and it has a positive effect on

inflammatory response 4, 5. Moreover HA is also capable of regulating the water balance acting on

osmotic pressure and flow resistance and selectively sieving the diffusion of plasma and matrix

proteins 5. So, after 7 days of conservative treatment with the use of Bionect Start® we obtained

resolution of symptoms and complete re-epithelialization of the lesions. (Fig.2)

The microbiological test result allowed us to give the patient a specific antibiotic therapy to treat the

infection on the tattoo. Probably the wound healing was also possible with the simple cleansing,

disinfection and antibiotic therapy without the use of collagenase, but in that case the scar would be

disfiguring with unsatisfactory aesthetic results. So the use of this collagenase has allowed us to

achieve good scars, and it has mainly allowed to keep the colors of the tattoo, requiring no editing it

after healing. (Fig.2)

Key Words: collagenase, hyaluronic acid, ulcerative lesions, tattoo

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The authors declare that they have no conflicts of interest to disclose.

Special thanks to Dr. Franco Bartolomei for his help in preparing this manuscript.

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Legend of figures

Fig.1: Ulcerative lesions of the right arm.

Fig.2: Complete re-epithelialization of the lesions of the right arm after 7 days.

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References

1. Falconi M, Teti G, Zago M, Galanzi A, et al. Influence of a commercial tattoo ink on protein

production in human fibroblasts. Arch Dermatol Res. 2009;301:539-47.

2. Kluger N, Plantier F, Moguelet P, Fraitag S. Tattoos: natural history and histopathology of

cutaneous reactions. Ann Dermatol Venereol. 2011;138:146-54; quiz 144-5, 155.

3. Ramundo J, Gray M. Collagenase for enzymatic debridement: a systematic review. J Wound

Ostomy Continence Nurs. 2009;36:S4-11.

4. Hollander D, Schmandra T, Windolf J. Using an esterified hyaluronan fleece to promote

healing in difficult-to-treat wounds. J Wound Care. 2000;9:463-6.

5. Wisniewski HG, Hua JC, Poppers DM, Naime D, et al. TNF/IL-1-inducible protein TSG-6

potentiates plasmin inhibition by inter-alpha-inhibitor and exerts a strong anti- inflammatory

effect in vivo. J Immunol. 1996 Feb;156:1609-15.

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Figures

Fig.1: Ulcerative lesions of the right arm.

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Fig.2: Complete re-epithelialization of the lesions of the right arm.